There is growing concern about the lack of progress in addressing poverty and the inequalities that persist in all aspects of South African society. This includes the substantial inequalities in health status between socio-economic groups, with the poorest bearing the heaviest burden of ill-health – not only in terms of what have been seen traditionally as ‘diseases of poverty’ such as communicable diseases (e.g. tuberculosis, HIV), diarrhoea and malnutrition but also increasingly in terms of non-communicable diseases (e.g. hypertension/high blood pressure). However, poorer groups have much worse access to health care and lower levels of health service use than richer groups.
Differentials in the use of health services are in no small measure influenced by the inequalities in the distribution of health services (facilities and health professionals) across provinces and districts within provinces. Government spending on basic health services ranged from R617 per person in the worst resourced health district to nearly three times more (R1679) in the best resourced district in 2016/17.
These differences are driven by the block allocation of tax funds to provinces, with each province having autonomy to decide on allocations between the health and other sectors, as well as the allocation of budgets to individual health facilities by provincial health departments on the basis of historical allocations (rather than the health-care needs of communities served by each facility).
The highly skewed distribution of resources, particularly health professionals, between the public and private health sectors also contributes to differentials in access to and use of health services across socio-economic groups.
Even where communities have physical access to health services, many public health facilities are regarded as providing poor-quality care. Sometimes this is related to resource shortages such as essential medicines being out of stock or lacking basic diagnostic equipment, but discourteous treatment of patients by health workers is also seen as widespread and deeply problematic.
A fundamental flaw in the public health system is that the national and provincial departments of health make all the key decisions affecting patient quality of care but they are not directly accountable for patient outcomes. Instead, accountability for service delivery and patient outcomes is laid at the door of facility level managers.
One of the key drivers of inefficiency, inadequate service quality, poor staff morale and other negative features of public sector health services is the lack of decision-making authority at the provider level. Hospital and other health facility mangers have very little authority to make decisions; instead, they have to send requests up the chain of command to provincial health departments. Not only does this create long delays in responding to issues that often have serious implications for service delivery, it is inefficient and contributes to managers being seen as unresponsive to their staff and patients. The lack of delegation of authority to enable facility managers to make all operational decisions necessary to ensure effective patient care, while holding them accountable for patient outcomes, disempowers managers and compromises service delivery.
Could the proposed National Health Insurance reduce these inequalities?
There are many misconceptions about the proposed NHI reforms, partly created by the unfortunate use of the term ‘insurance’, which conjures up visions of a large medical scheme. The reforms in fact propose improved tax funding for health services, but more importantly focus on ways of ensuring that limited financial resources are used efficiently to provide accessible, quality health services that meet the health needs of the population.
This would be done by creating a new autonomous public entity (the NHI Fund), which would be tasked with carefully identifying the health needs of different communities and directly purchasing the health services that are needed from public and private health-care providers, and where public providers would have delegated decision-making authority. There would be explicit contracts with providers, spelling out what is expected in terms of the range, quantity and quality of health services. There would also be changes in the way providers are paid, with allocations directly to each sub-district for primary care services based on the size of the population served and other indicators of need for care.
This approach would reduce inequalities in the geographic distribution of resources dramatically. These reforms provide a basis for directing resources in line with the health needs of South Africans, for drawing on the large number of health professionals who work in the private sector to benefit all, and for holding public and private providers accountable for the quality of their services.
However, the prevailing macro-economic and governance context is not conducive for establishing the proposed NHI Fund as an autonomous public entity in the short term. There is considerable risk in a large proportion of the financial resources available for health services being located in a single institution, and ironclad risk management and governance have to be put in place, drawing on international best practice with similar independent strategic purchasing entities.
While strategic purchasing would allow current health-care funding to be used more efficiently and equitably, public funding for the health sector will need to be increased to ensure that all South Africans have access to quality health care. With the sudden introduction of ‘free higher education’, and the many competing claims for increased public funding in other social sectors where there are urgent needs, such as early childhood development and basic education, transparency in prioritising government spending becomes critical.
What can be done now?
Research that contributed to the Mandela Initiative’s work on strategies to overcome poverty and inequality proposes two key interventions that could help to address inequalities in access to quality health care in the short term. These are centralising the allocation of public funds for health, and decentralising decision-making authority.
Direct allocation of health budgets from the national level to sub-districts and hospitals on the basis of the needs of the communities they serve would reduce resource inequalities. Piloting the delegation of management authority to individual public hospitals and to sub-district management teams for primary health-care services, combined with strong governance and accountability structures at local level, would help to address many of the persistent challenges that face public sector health facilities. These interventions would also lay the groundwork for introducing a strategic purchasing entity once the national governance context has improved.
The Mandela Initiative, a multi-sectoral platform to investigate and develop strategies to overcome poverty and inequality, is convening a national workshop this week to consider the recommendations from five years’ work, and with the aim to reinvigorating the debate about accelerating the pace of change in South Africa.
(Photo: Gallo Images / Sowetan / Tiro Ramatlhatse)